CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No. -
INSTRUCTIONS
1. Claims for death, injury to person or to personal property must be filed not later than six (6) months after the occurrence. (Gov. Code Sec.9112)
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2) RECEIVED
Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom. APR 1 7 2024
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) CITY CLERK'S OFFICE TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (if natural person)
City and State Home telenhone Number
Los Anades, CA
City and State Business Telephone Number
Business Address of Claiman Heet 223| E Vemon. CA
Give address to which you desire notices or communications to be sent regarding this claim:
Los Angeles CA 90017
How did DAMAGE or INJURY occur? Give full particulars.
Commuting te work on E Washington Blud, encauntered two potholes which damaged my front right till immidiately.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
4/2/24 around 12pm
Where did DAMAGE orINJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Pathole is located at 2212 E Washington Blvd
What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any. causing the injury or damage, if known:
Fee relent and redne o
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
What AMOUNT do you claim of each item of injury ordamage as of date of presentation ofthis claim, giving basisof computation:
$545.90
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury or damage, giving basis of computation:
$545.90
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Proavessive #950242536 No caverage for tive
Expenditures made on account of accident or Injury: (Date - Item) (Amount) 413/24 - Tire and Alignment
Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street corners.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself r your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of vourself or vou ehicle at the time of accident by "8 1" and the point of Impact by "X.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
railroad
2231 E
71 Fag,
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURB,
77 I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Date:
relationship to Claimant:
Chan Tian 17 24
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) Chao Tian
4/10/24
City of Vernon
Public Works Department
4305 Santa Fe Ave
Vernon, CA 90058
Subject: Reimbursement Claim for Blown Tire Damage Due to Unfixed Potholes Dear Sir/Madam,
I am writing to file a reimbursement claim for damages incurred to my vehicle as a result of unfixed potholes on 2212 E Washington Bld in Vernon, California. My name is Chao Tian, and the incident occurred on April 2nd, 2024.
Description of Incident:
While commuting to work on E Washington Blvd, I encountered two substantial potholes which led to immediate damage to my front right tire. The blowout caused my vehicle to swerve dangerously, nearly colliding with a parked vehicle on the roadside. Moreover, the abrupt incident significantly impacted the health of an older passenger in my car who suffers from heart conditions. He is scheduled for a check-up this month to evaluate the extent of the harm caused.
After the incident, I promptly had my vehicle towed to Pacific Coast Tires Inc, located at 3056 Bandini Blvd. Interestingly, within a short span of time, another vehicle was towed to the same establishment with identical blown tire damage resulting from the same pothole. Enclosed are photographs of the potholes, as well as the damaged tire and vehicle, along with timestamps to corroborate the sequence of events.
Financial Repercussions:
The total cost incurred for the replacement tire, alignment, and labor amounted to $545.90, as quoted by Pacific Coast Tires Inc. I am therefore requesting compensation for this amount, as the damage was a direct consequence of the neglected road maintenance in the City of Vernon.
Enclosed Documents:
Photographs of the two potholes on E Washington Blvd.
Photographs of the blown tire and damaged vehicle.
Timestamped photographs indicating the time of the incident.
Quotation from Pacific Coast Tires Inc for the replacement tire, alignment, and labor.
I trust that the City of Vernon will duly investigate this matter and provide timely reimbursement for the damages suffered. Please contact me at or Should you require any further information or clarification regarding this claim.
Thank you for your attention to this matter.
Sincerely,
Chao Tian
CITY FIBERS, I n
3:22 \ • 72
Vernon
Edit
April 21:06 PM
O LIVE
My
Tire
3:22 4
Vernon Edit
April 2 1:42 PM
@ LIVE
Second
Vehicle
V
Same
Pathole
PACIFIG COAST TIRES
3056 E BANDINI BLVD GOOD/TEAR BRIDGESTOnE Firestone BFGoodrich KELLYNSTIRES IRONMAN BUMROYALE VERNON, CA 90058 GNMENT SERVICES AVAILABLE! © WE SPECIALIZE IN TPM SENSORS L 3232642366
ad Service • Airing Programs • Fleet Inspections Date Work Orderf https://pacificcoasttiresinc.com E. Bandini Blvd. Vernon, CA 90058 104022
Cashier: BRYAN RUBIO 1-2366 Cell: (323)614-6533 Fax: (323) 264-2262 All neve & retread tires Purchased from Pacific Coast Tire Inc. are warranted from the
:[email protected] • WWW.PACIFICCOASTTIRESINC.COM vanufacturer against defects in worksmanship an Transaction 101754 naterials for the life of the original trea ¡ATION DELIVER TO LOCATION
Total $545.90 Name
CREDIT CARD SALE $545.90
dress
AMEX 1008
unty, State & Zip
Retain this copy for statement Start Time
Borone Mileage Start
validation
vers Cell# Mileage Finish Time Finish
03-Apr-2024 1:51:17P aton Code Reference # Time Call Received $545.90 | Method: CONTACTLESS
AMERICAN EXPRESS ce Make Purchase Order #
XXXXXXXXXXXX1008
Vin# Serviceman Name
VALUED CUSTOMER
Reference ID: 409400505164
TIRE SIZE DESCRIPTION UNIT PRICE F.E.T. TOTAL
Auth ID: 827865
MID: ********1889
AID: A000000025010801
AthNtwkNm: AMEX
SIGNATURE
Online: https://clover.com/p
/GPJEJRJ7A2YA8
Payment GPJEJRJ7A2YA8
Clover Privacy Policy
https://clover.com/privacy
LABOR
Ai at the wheels be retorqued
FET
ation.
Set earner Serial# New Reason Replaced
SALES TAX
Serialik Old Serial# Old Remaining 32nds Off Casing Brand TOTAL
32nds
LF RR LR Duals RFI RFO LFI LFO F-Flat R-Replace S-Switch Pass / Lt Truck RF
Medium Truck RF LF RFI RFO LFI LFO RRI RRO LRI •LRO
Reason For Replacement
Worn Out Run Flat_ Cut Through Tread Cut Through Sidewall Tread Separation Sidewall Separation Casing Failure_ Retread Failure _ Valve Problem Please Send Payment to: Pacific Coast Tire., 3056 E. Bandini Blvd. Vernon, CA 90058 Limited Warranty on all Retread Tires - No Warranty on Used Tires Pacific Coast Tire is not responsible for Customer Tires or Casings left over 30 Days
SECURITY AGREEMENT
BY SIGNING BELOW
thereby certity that i have received a written copy of this estimate of service, repairs or parts needed on the Buyer grants to the seller a security interest in the above merchandise until the indebtedness is paid in full. Until vehicle stated and hereby authorize service, repairs or parts required by this estimate and hereby grant you Davment in full has been made. Buver agrees that: (1) Seller shall retain title of said merchandise: (2) Buyer will have and/or your employees permission to operate the vehicle herein described on the streets, highways or he risk of loss or damage; (3) Buyer will not sell, transfer possession or remove or encumber above merchandise isewhere for the purpose of testing and/or inspection. An express mechanics len is hereby acknowledged hout Seller's witten consent: (4) if Buyer delaults in the payment of any installment, Seller may declare the entire on above vehicle to secure the amount of repairs thereto which have authorized and are not covered by balance due and payable and Seller may at its option take back the merchandise or alfirm the sale and hold Buyer warranty, we will not be held responsible for loss or damage to vehicle or articles left in vehicle in case of fire Table for the unpaid balance, including any reasonable attorney fees or collection charges permitted by law: (5) The Seller shall have all the rights, options and duties under the Uniform Commercial Code of this state. Secunty interest theft, accident or any other cause beyond our control. in the goods herein described shall terminate as the unpaid balance for them are paid.
SIGNATURE / FIRMA EMPLOYEE DATE SIGNED
PRINT NAME / ESCRIBA SU NOMBRE